RN Medical Claims Auditor & Compliance Expert

CommunityCare HMO Inc.; Tulsa (OK); Sur place; USD 60 000 - 85 000; Plein temps

Résumé du poste

CommunityCare HMO Inc. is seeking a Medical Review Examiner Nurse to audit provider and facility claims in Oklahoma. You will evaluate clinical appropriateness, coding accuracy, and charge validity, coordinating with claims processing and providers.

Responsibilities include reviewing complex claims, maintaining audit tracking, generating reports, and advising internal teams on clinical service adequacy. A RN or LPN in good standing with five years in hospital/clinic health plan operations is

Qualifications

• Current, active RN or LPN license in Oklahoma.
• Associates Degree required; Bachelor’s Degree preferred.
• Five years of work experience in hospital, clinic or health plan clinical operations.
• Experience or familiarity with state and federal healthcare regulations preferred.

Responsabilités

• Review claims by requesting medical records and other documents to evaluate for clinical appropriateness, coding compliance and validity of charges.
• Document ineligible charges and provide communications internally for claims processing and externally to providers.
• Provide review of complex claims for further research meeting the MRE pend criteria with Medical Director and/or other departments.
• Maintain tracking database including self-audit for quality control; compile and analyze data and prepare routine reports; identify trends and formulate recommendations.
• Serve as an internal resource to provider services, contracting, claims, medical management, configuration, and appeals & grievances; provide guidance on clinical appropriateness of services.
• Maintain files of MRE records; participate in special projects and audits as assigned.

Connaissances

ICD-9/ICD-10 codes

HCPCS/CPT-4 codes

Claims processing software

Microsoft Office

Communication skills

Formation

Oklahoma RN/LPN licensure

Associates Degree

Bachelor's Degree preferred

Outils

Claims processing software

Microsoft applications

Description du poste

CommunityCare HMO Inc. is seeking a Medical Review Examiner Nurse to audit provider and facility claims in Oklahoma. You will evaluate clinical appropriateness, coding accuracy, and charge validity, coordinating with claims processing and providers.

Responsibilities include reviewing complex claims, maintaining audit tracking, generating reports, and advising internal teams on clinical service adequacy. A RN or LPN in good standing with five years in hospital/clinic health plan operations is